AAOS: Team Docs Must Address Conflicts of Interest

"You don't have to pay teams," football physician says

SAN DIEGO -- Official medical group-pro sports team partnerships should be banned in order to avoid conflicts of interest, according to two veteran National Football League team doctors.

"This has evolved into a business now. At the professional level, we have become commodities of the leagues," said Anthony Miniaci, MD, of the Cleveland Clinic.

"Our conflicts of interest are real," added Miniaci, who is a physician for the Cleveland Browns and an orthopedic consultant for the Toronto Blue Jays.

"Don't do it," warned Russell Warren, MD, of Hospital for Special Surgery in New York City, of the team partnerships in which medical groups often pay to treat players in exchange for signage and other sponsorship perks.

"That's a huge conflict...You don't have to [pay teams] and you shouldn't," added Warren, formerly a team physician for the New York Giants for more than 30 years.

Miniaci and Warren spoke at a seminar at the American Academy of Orthopedic Surgeons annual meeting. In general, they spoke highly of their experiences with professional sports teams, but also called on their colleagues to reform some practices with teams. They also critiqued a recent controversial report on football player safety.

Warren discussed the difficulty of balancing responsibility for player safety with the urge to win. He showed a slide featuring two Vince Lombardi championship trophies juxtaposed around an old Giants helmet, calling winning "a reasonable goal, but don't get carried away with it."

He said team physicians must be willing to stand up to coaches who want players to suit up with injuries. He recounted sparring with former Giants coach Bill Parcells over players' readiness to return to play. But he also disputed another coach's decision to sit a starting receiver with an injury for the Super Bowl, and told a skeptical Parcells that a nose tackle was healthy enough to play after undergoing back surgery.

The role of team doctors in football has come under scrutiny, particularly after the 2016 release of the Football Players Health Study at Harvard University that addresses conflicts of interest. The report recommended teams station a second group of medical specialists on the field, independent of the league, similar to the unaffiliated neurologists who attempt to spot and treat concussions, with varying degrees of success.

However, Warren called the idea of independent specialists "totally ridiculous," pointing out that they lack the institutional knowledge team doctors have about players' histories, not to mention the rapport with players.

"There's no way to impart all that information to them" and help the independent providers make prudent return-to-play recommendations, Warren added.

But Miniaci cautioned that the idea of independent specialists is "something that has to be considered with all the conflicts of interest now." Rather than fighting it, sports medicine specialists need to meet with key players in the game -- leagues, teams, players, agents, and players' associations -- and "take control as physicians."

Warren also criticized media coverage of sports concussion, saying the New York Times in particular has overemphasized brain injury in sports versus brain injuries from other causes. According to a new CDC report, older adult falls accounted for a much larger proportion of the increase emergency department visits for traumatic brain injuries (TBI) from 2007-2013, for example. The report states "Although considerable public interest has focused on sports-related concussion in youth, the findings in this report suggest that TBIs [traumatic brain injuries] attributable to older adult falls, many of which result in hospitalization and death, should receive public health attention."

Media attention and public scrutiny are part and parcel of being a team physician, Miniaci noted. Other drawbacks include time commitments and travel, and the pressure to win, Miniaci said. It’s difficult for specialists in a private practice to manage the gig and, nowadays, “there is a lack of trust out there” among players for team doctors.

Both speakers emphasized that they ultimately have enjoyed their experiences as team doctors. Such a role can help build a practice and business, enhance a physician's professional reputation, and potentially improve job satisfaction, Miniaci said.

Warren shared positive anecdotes, such as when he recommended the San Francisco 49ers sign the aforementioned nose tackle Jim Burt after the Giants declined to re-sign him in 1989. Burt, who had undergone back surgery, then played parts of three more seasons with the 49ers.

Warren also suggested that wide receiver Plaxico Burress still play in the 2008 Super Bowl with a sprained medial collateral ligament in his left knee, among other injuries. Giants coach Tom Coughlin was considering sitting him because Burress could not cut and turn in one direction (his right). But Warren said he assured coach and player that Burress would not do further damage to the knee by playing, so he encouraged the receiver to “let me numb you” before the game. On the Giants' final drive, Burress faked to his right — “which he couldn’t go!” Warren said — cut left, and caught the winning touchdown pass.